Evaluation of Technical Efficiency of Nursing Care in US Critical Care Units BY ARI MIN BSN ...

81 Pages·2016·1.2 MB·English

by  A-ri Min

Evaluation of Technical Efficiency of Nursing Care in U.S. Critical Care Units

BY

ARI MIN
B.S.N., Yonsei University, Seoul, South Korea, 2008
M.S.N., Yonsei University, Seoul, South Korea, 2012

THESIS

Submitted as partial fulfillment of the requirements
for the degree of Doctor of Philosophy in Nursing Sciences
in the Graduate College of the
University of Illinois at Chicago, 2016

Chicago, Illinois

Defense Committee:

Linda D. Scott, PhD, RN, NEA-BC, FAAN, Chair and Advisor
Catherine Vincent, PhD, RN
Catherine J. Ryan, PhD, RN, APN, CCRN, FAHA
Chang Gi Park, PhD
Taewha Lee, PhD, RN, Yonsei University
To my husband and my parents
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ACKNOWLEDGEMENTS
First, I would like to thank my advisor and dissertation chair, Dr. Linda Scott, for her
insightful guidance, cheerful encouragement, and full support. Dr. Scott has offered me many
learning opportunities throughout my doctoral program and has been particularly generous with
her time in helping me to accomplish my research goals. In addition to her assistance with this
dissertation, Dr. Scott has shared opportunities with me for publications, presentations, and grant
applications. I am grateful not only for her thoughtful guidance, but also her patience and
inspiration. Without her continued support and encouragement, I could not have completed my
PhD program.
I also would like to express my sincere gratitude to my dissertation committee for sharing
their time and expertise in guiding my study. I am extremely thankful to Dr. Chang Gi Park not
only for his support in development of my study, but also for his generous contribution of his
statistical expertise throughout the research process. I also sincerely appreciate the support of Dr.
Catherine Vincent, who encouraged me with kind words and strengthened the theoretical portion
of my dissertation work. In addition, I would like to extend my special thanks to Dr. Catherine
Ryan for her invaluable advice in planning my study and shaping my approach. Finally, I offer
my special appreciation to Dr. Taewha Lee for overcoming the obstacles posed by distance to
provide great support and a strong contribution to this study based on her expertise in nursing
administration research.
I am thankful to have received two research funding awards for my dissertation study, the
Midwest Nursing Research Society Dissertation Research Grant and the Sigma Theta Tau Alpha
Lambda Research Award.

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ACKNOWLEDGEMENTS (continued)

I am extremely thankful to many additional individuals for their contribution to my study.
Special thanks must go to the nurses of Korea, especially the PICU nurses at Samsung Medical
Center in Seoul, who inspired me to pursue my PhD degree in order to contribute to a better
nursing work environment through my research. Equally deserving of thanks are Dr. In Sook
Kim, Ms. Geum Moon Lee, Dr. Young-Ju Kim, Dr. Gwang Suk Kim, and Dr. Hyunsook Shin in
Korea, who have motivated me to move forward to accomplish my goal. I am also extremely
thankful to Dr. Mi Ja Kim for helping me to overcome all obstacles and for motivating me to
support the next generation of nursing students as she supported me. Moreover, I would like to
express my thanks to all the faculty members of the College of Nursing.
As an international student for whom English is a second language, I would like to
acknowledge Mr. Jon Mann for his time and dedication in editing all of my academic papers
throughout my doctoral program as well as Dr. Harveen Mann for her friendship and warm
support. I also have benefited from the truly professional support provided by the administrative
staff of the college: Ms. Kimberly White, Natalie Meza, and Tina Kavukattu.
There is no way to express how much it has meant to me to be a PhD student at the
University of Illinois at Chicago. I cannot neglect to thank the friends and colleagues who went
through hard times with me, cheered me on, and celebrated each of my accomplishments:
Minkyung Kang, Sujeong Kim, Meenhye Lee, Haeyoung Min, Yoo Mi Jeong, Jongwon Yoo,
Seung Eun Lee, Inah Kim, KeKe Lin, Thao Griffith, Feyi Sangoleye, Hening Pujasari, Julie
Johnson Lambert, Holly Houston, Jeff Williams, Alysha Hart, Amy Johnson, and all the other
current and former graduate students I have known. These brilliant friends and colleagues have
truly inspired me over the years.
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ACKNOWLEDGEMENTS (continued)
I deeply thank my family, especially my parents, Kyungseon Min and Yangsook Kang,
for their unconditional trust, constant encouragement, and endless love. It was their love that
raised me up again when I became exhausted or frustrated. Finally, I owe my deepest gratitude
and love to Jiyong Kim, my husband. He has been my best friend and great companion. He has
loved, supported, encouraged, and entertained me throughout this challenging period and helped
me to move forward in the most positive way.

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TABLE OF CONTENTS
CHAPTER PAGE

I. ORGANIZATIONAL FACTORS ASSOCIATED WITH TECHNICAL
EFFICIENCY OF NURSING CARE IN U.S. CRITICAL CARE UNITS
A. Background………………………………………………..…………… 1
B. Methods……………………………………………………...….……... 4
1. Data Source………………………………………...…..………. 4
2. Measures……………………………………………...………... 6
3. Analysis………………………….…………………………….. 8
a. Data Envelopment Analysis…………………….……... 8
b. Multilevel Modeling………………...…………..…...… 9
C. Results………………….………………………………………………. 10
1. Relative Technical Efficiency of Nursing Care in U.S. Critical
Care Units…………………………………...…………………. 10
2. Organizational Factors Affecting Technical Efficiency of
Nursing Care………………..…………………………………. 11
D. Discussion…………………………..………………………………….. 13
E. Limitations……………………………………………………………... 17
F. Conclusion…………………………………………….……………….. 18
G. References……………………………………………………………… 19

II. IMPACT OF MEDICARE ADVANTAGE PENETRATION AND
HOSPITAL COMPETITION ON TECHNICAL EFFICIENCY IN U.S.
CRITICAL CARE UNITS
A. Background…………………………………………………………….. 34
B. Theoretical Foundation………………………………………………… 36
C. Conceptual Model……………………………………………………... 38
D. Purpose…………………………………………………………………. 38
E. Methods…………………………………………………………..……. 39
1. Research Design……………………………………………….. 39
2. Data Sources and Sample………………………..…………….. 39
3. Variable Construction………………………………………….. 39
a. Dependent Variable……………………………………... 39
b. Independent Variables: Measures of Environmental
Factors…………………………………………………... 41
c. Control Variables: Measures of Organizational
Factors………………………………………………….. 41
4. Analysis………………………………………………………... 42
a. Data Envelopment Analysis……………………………. 42
b. Multilevel Modeling……………………...…………….. 43
F. Results……………………………………………………………….… 45
G. Discussion……………………………………………………………… 47
H. Limitations……………………………………………………………... 51
I. Conclusion……………………………………………………..………. 52
J. References……………………………………………………………… 54
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TABLE OF CONTENTS (continued)
CHAPTER PAGE

APPENDICES………………………………………………………………... 66
VITA………………………………………………………………………….. 67

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LIST OF TABLES
TABLE PAGE

I. ORGANIZATIONAL CHARACTERISTICS OF INCLUDED AND
EXCLUDED CRITICAL CARE UNITS…………………………….….. 23

II. VARIABLE DESCRIPTIONS………………………………………...… 24

III. DESCRIPTIVE STATISTICS OF INPUTS AND OUTPUTS………….. 25

IV. TECHNICAL EFFICIENCY OF NURSING CARE SCORES FROM
DATA ENVELOPMENT ANALYSIS………………………………….. 25

V. TECHNICAL EFFICIENCY OF NURSING CARE SCORES BY
MAGNET STATUS AND HOSPITAL BED SIZE…………………….. 26

VI. BIVARIATE ANALYSIS BETWEEN TECHNICAL EFFICIENCY OF
NURSING CARE AND PREDICTORS.……………………………….. 26

VII. RESULTS OF MULTILEVEL MODELING ON TECHNICAL
EFFICIENCY OF NURSING CARE………..…………………………... 27

VIII. R ESULTS OF MULTILEVEL MODELING BY LEVEL OF
TECHNICAL EFFICIENCY IN CRITICAL CARE UNITS……….…... 28

IX. OPERATIONALIZATION AND DATA SOURCES OF STUDY
VARIABLES……………………………….……………………………. 59

X. DESCRIPTIVE CHARACTERISTICS OF CRITICAL CARE UNITS... 60

XI. RESULTS OF DATA ENVELOPMENT ANALYSIS…………………. 61

XII. BIVARIATE ANALYSIS BETWEEN TECHNICAL EFFICIENCY OF
NURSING CARE AND PREDICTORS………………………………… 61

XIII. R ESULTS OF MULTILEVEL MODELING FOR TECHNICAL
EFFICIENCY OF NURSING CARE……………………………………. 62

XIV. C OMPARISON OF MULTILEVEL MODELING BY LEVEL OF
TECHNICAL EFFICIENCY IN CRITICAL CARE UNITS………….... 63

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LIST OF FIGURES
FIGURE PAGE

1. Distribution of technical efficiency of nursing care……………………... 29
2. Distribution of random effect of nurse-to-patient ratio
slope……………………………..………………………………….……. 30

3. Relationship between nurse-to-patient ratio and fitted technical
efficiency of nursing care by hospital Magnet status……………………. 31

4. Relationship between nurse-to-patient ratio and fitted technical
efficiency of nursing care by hospital bed size………………………….. 32

5. Relationship between nurse-to-patient ratio and fitted technical
efficiency of nursing care by Medicare case mix index…………………. 33

6. Conceptual framework based on the Structural Contingency Theory...…. 64

7. Distribution of technical efficiency of nursing care scores in data
envelopment analysis………..…………………………………………… 65

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LIST OF ABBREVIATIONS

CAUTI Catheter-Associated Urinary Tract Infection

CCU Critical Care Unit

CI Confidence Interval

CLABSI Central Line Catheter-Associated Blood Stream Infection

CMI Case Mix Index

CMS Centers for Medicare and Medicaid Services

CRS Constant Returns to Scale

DEA Data Envelopment Analysis

HAPU Hospital-Acquired Pressure Ulcer

HHI Herfindahl-Hirschman Index

HMO Health Maintenance Organization

HPPD Hours Per Patient Day

ICC Intra-class Correlation Coefficient

LPN Licensed Practical Nurse

NDNQI National Database of Nursing Quality Indicators

RN Registered Nurse

SCT Structural Contingency Theory

SE Standard Error

UAP Unlicensed Assistive Personnel

VAE Ventilator-Associated Event

VRS Variable Returns to Scale

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